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“Jøkulfell” SAR analysis

“Jøkulfell” SAR analysis. Presentation - MFMA June 22nd. Maritime Solutions June 2005. Agenda. Introduction STEP-Analysis Cause analysis Alternative potential scenario Improvement areas Ideal scenario Discussion. Background.

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“Jøkulfell” SAR analysis

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  1. “Jøkulfell” SAR analysis Presentation - MFMA June 22nd Maritime Solutions June 2005

  2. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

  3. Background • At 19:53 UTC on the 7th of February 2005 Tórshavn radio received an automatic distress signal (DSC) from the general cargo vessel Jøkulfell. • The Maritime Rescue Coordination Centre (MRCC) in Tórshavn initiated a Search And Rescue (SAR) operation involving both helicopters and ships. • After the accident the MRCC Tórshavn was criticised for not having sent a Faeroe Bell 412 SAR helicopter earlier than what was done instead of sending a Danish frigate holding a Lynx helicopter.

  4. Objective • Assess the dispositions of MRCC-Tórshavn with respect to the SAR operation “Jøkulfell”, with focus on why the SAR helicopter Bell 412 was not sent to the scene of accident before 2.5 hours after the initial distress call. • Evaluate possible actions to be taken in order to assure a rapid and accurate response in future SAR operations

  5. Conclusions • The disposition of the Danish frigate instead of the Bell 412 helicopter was not unreasonable. • It could however have been reasonable to send one of the helicopters to the scene at an earlier stage. • The later response was a result of several factors ranging from training and preparedness, inadequate communication and inadequate procedures.

  6. Parties and resources • MRCC Tórshavn • Tórshavn radio • Atlantic Airways (AA) • Færøyenes Kommando (FRK) • Fisheries inspection (FI)

  7. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

  8. Cirumstances • The distress position was about 50 nm NE of Faroe Islands (See map). • The few DSCs that have earlier been received at MRCC Tórshavn have been false. • DSC is only received once or twice a year. • There were no vessels close to the position, but both the coastguard vessel Brimil and the Danish Frigate, Vædderen, were in fortunate positions off the north coast having three to four hours sailing distance to the position. • There was also a SAR helicopter (Bell 412) stationed at Vagar airport. • During the SAR operation the wind built up from strong breeze to gale. The weather conditions made takeoff, landing and rescue difficult for the helicopters involved.

  9. STEP Diagram • The following five foils outline the scenario describing the first phases of the SAR response to Jøkulfell 7. February 2005. • Actors involved is plotted vertically to the left • Time is plotted horizontally • Relevant events with time is plotted for the relevant actor and point in time. • Black event-nodes illustrate decisions to dispose SAR resources. • Grey event-nodes illustrates events that bring information about the ship to MRCC Tórshavn. • White event-nodes are the most important remaining events. • The STEP diagram is supported with a list of the events that contain more detailed descriptions.

  10. 20:00 20:30 20:18 – Sends mayday relay on MF 20:31 – Channel 16 open 19:53 – Tórshavn Radio receives automatic DSC 20:45 20:20 –Confirmation of name and rough position 19:56 – MRCC gets informed about the DSC 20:09 – MRCC leader is informed 20:38 19:58 – “On hold” watch is called 20:00 – MRCC change of watch 20:17 – Is informed that Bell 412 can fly in this weather 20:31 – MRCC informs FRK about the situation 20:30 – Hears that Brimil is sailing towards a potential accident 19:57 – Brimil is sent to position by MRCC 20:19 – MRCC informs. Is told to be “stand by”. 20:06 – MRCC informs AA about the situation Ca. 20:20 – Visit a local seaman for weather advices Response – DSC received Time Tórshavn Radio MRCC Tórshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov)

  11. 20:30 21:00 20:33 – Sends mayday relay on both MF and VHF 20:38 – MRCC decides to send Vædderen 20:45 – MRCC leader arrives 20:44 – Sends fax to FRK 20:33 – FRK asks for information on fax 20:52 – FRK confirms and sends duty officer 20:35 – Receives mayday relay 20:45 – Calls FRK and asks what to do Response – DSC received Time Tórshavn Radio MRCC Tórshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov) 20:09 20:20

  12. 21:00 21:30 21:18 – Talks to Vædderen 21:42 – Sends SAR siterep 21:08 – Gets call from Aberdeen. EPIRB signal. 21:18 – Give “ok” for Vædderen to send Lynx helicopter 21:11 – MRCC Reykjavik says there are 11 POB 21:18 – Decides to send Lynx helicopter 21:22 – Start preparing Lynx helicopter 22:04 21:19 – MRCC requests to make the ship ready 21:10 – MRCC requests to make the helicopter ready 21:23 – Air traffic controller in tower 21:25 – MRCC situation update 21:37 – AA asks about position and informs about weather Response – EPIRB received Time Tórshavn Radio MRCC Tórshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov)

  13. 22:00 22:30 22:03 – Halifax informs about new beacon signal 21:22 22:04 – Lynx helicopter is airborne 22:22 – Lynx sees lights 22:34 22:39 21:58 – MRCC informs about new position 22:12 – MRCC asks if AA can fly to Klaksvik 22:27 – The AA Bell 412 is given “Go” Helicopter rescue Time Tórshavn Radio MRCC Tórshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov)

  14. 22:30 23:00 22:22 22:34 – Sees the first man alive 23:04 – Has picked up 5 survivors 23:22 – Lands on Vædderen 22:27 22:31 – MRCC updates tower on situation 22:36 – MRCC says there are people in the water 22:39 – AA Bell 412 airborne 23:24 – Is on scene Helicopter rescue Time Tórshavn Radio MRCC Tórshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov)

  15. Helicopter and ship SAR Time 23:30 23:00 Tórshavn Radio MRCC Tórshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov) 23:30 to 16:30 – The Bell 412 helicopter (once at night and once in the morning), Vædderen (On scene commander from 00:06), Brimil, Tjaldrid, Viktor Mironov, Leinebris and a Fokker airplane from Iceland search the area. Between 07:58 and 11:07 4 bodies were picked up from the water. Tjaldrid picked up 3 and Brimil 1. There are many containers floating around, together with a lot of other debris. Several life rafts, life jackets and EPIRB’s were picked up.

  16. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

  17. BASIC CAUSES IMMEDIATE CAUSES LACK OF CONTROL INCIDENT LOSS Inadequate System Standards Compliance Personal Factors Job or System Factors Substandard Acts or Practices Substandard Conditions Event or Contact Unintended Harm or Damage Loss causation model

  18. BASIC CAUSES IMMEDIATE CAUSES LACK OF CONTROL INCIDENT LOSS “Late arrival of SAR resources “ “Loss of confidence and reputation” Incident and loss

  19. BASIC CAUSES IMMEDIATE CAUSES LACK OF CONTROL INCIDENT LOSS Less than adequate decision making at MRCC Tórshavn Loss of confidence and reputation Late arrival of SAR resources Immediate causes Main decision parameters: • What was the available information about the distress situation? • What were the available SAR resources? • What would be the remaining SAR capacity on Faeroe Islands? .

  20. BASIC CAUSES IMMEDIATE CAUSES LACK OF CONTROL INCIDENT LOSS Preparedness Operational procedures Responsibility Communication Less than adequate decision making at MRCC Tórshavn Loss of confidence and reputation Late arrival of SAR resources Basic causes Main basic causes • Less than adequate training • Less than adequate operational procedures and practice • Less than adequate communication • Unclear responsibilities

  21. BASIC CAUSES IMMEDIATE CAUSES LACK OF CONTROL INCIDENT LOSS LTA Preparedness Operational procedures Responsibility Communication Less than adequate (LTA) decision making at MRCC Tórshavn Loss of confidence and reputation Late arrival of SAR resources Lack of control There exists no formal system that • assures that the competence of the MRCC personnel is adequate. • assure adequate communication, • maintain clear levels of responsibility. • assure overall quality assurance system for MRCC Tórshavn LTA Competence, Communication and Quality management systems quality system

  22. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

  23. Time: 19:53 22:22 21:08 23:55 16:15 EPIRB received Alternative potential scenario • Actual Time: 19:53 20:25 21:45 23:55 16:15 Phase 1: Unconfirmed distress signal Phase 2: Unknown severity Phase 3: SAR from air Phase 4: SAR from ships Confirmation of Jøkulfell position DSC received End Helicopter at position Brimil at position

  24. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

  25. There exist evident needs for new and improved procedures and guidelines at MRCC Tórshavn • Map over Resources • There should exist a clear and updated map of all the available resources and what they can and cannot be used for. • SAR manual (overall) • The SAR manual is in a general need of improvement. This is especially true since MRCC has expressed wishes to be ISO certified. • SAR Plan (Distress / Mayday procedure) • It should be perfectly clear for everyone what to do when an emergency happens. • Change of watch duringemergency situations • There should be a procedure for how the change of watch should work if the change happens during an emergency situation. • Communication with external parties • There should be established a common “language” between MRCC and external parties such as Atlantic airways, FRK and FI. • Meetings • There should be established regular internal meetings (monthly, weekly etc.) with a defined agenda where all people employed at MRCC Tórshavn should be able to bring up thoughts and ideas.

  26. Most of the organization and responsibilities during rescue operations are perceived as clear to those involved, but there are some areas that need to be better defined • Cooperation and communication between the parties involved • For example should the cooperation between Atlantic airways, FRK, MRCC, FI and Tórshavn radio be reviewed. It is essential that everybody knows who does what and when. • At MRCC • The decision authority and roles at MRCC needs to be looked over. The procedures states that the leader of MRCC has responsibility over and is the only one allowed to make most of the urgent and difficult decisions (for example which resources to send, whom to call in, etc.).

  27. Training and teambuilding will increase the understanding and build stronger relationships • Increased amount of training and exercises • It is recommended to conduct joined (MRCC, FRK, FI and AA) night training and joined rescue from the sea training with both rescue basket and rescue man. • Teambuilding • In order to increase understanding and improve relationships we also recommend joined teambuilding events including all parties involved.

  28. The agreements needs to be improved and AIS development continued • Agreement between Atlantic Airways and MFMA (MRCC) • The agreement is in an urgent need of improvement. Today, the cooperation between the two parties is not working as it should. • Agreement between MFMA (MRCC) and FRK • Could also be looked at and discussed. However, a lot of improvement can also be achieved through regular meetings and communication between the parties. • Agreement between MRCC and FI • The cooperation between MRCC and FI seems to be working well. There should however, in the future, also be written an agreement between these two parties as well, in order to avoid potential future misunderstandings. • Technical improvements • The Automatic Identification System (AIS) development should be continued.

  29. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

  30. Ideal scenario – alternative 1 • STEP ideal scenario – Vædderen is in a favorable position

  31. Response – DSC received Time 20:00 20:30 19:53 – Tórshavn Radio receives automatic DSC 20:10 – Sends mayday relay 19:55 – Try to contact the vessel Torshavn Radio MRCC Torshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov) 20:15 – MRCC decides to send Lynx 20:10 –Confirmation of name and rough position 19:56 – MRCC gets informed about the DSC 20:00 – MRCC contact Reykjavik 19:58 – “On hold” watch is called 20:05 – Is informed that Bell 412 can fly in this weather 20:13 – MRCC informs FRK about the situation 19:57 – MRCC informs about the situation 20:00 – Vædderen is sent to position by MRCC, starts preparing Lynx 20:15 – Lynx helicopter is given “Go” 20:00 – Aletrs Lynx helicopter 19:57 – Brimil is sent to position by MRCC 20:19 – MRCC informs. Is told to be “stand by”. 19:57 – MRCC informs about the situation, AA gets prepared

  32. Response – DSC received Time 20:30 21:00 20:33 – Sends mayday relay 20:31 – Channel 16 open Torshavn Radio MRCC Torshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov) 20:30 – MRCC change of watch 20:30 – Lynx helicopter is airborne 21:05 – Is on scene

  33. Ideal scenario – alternative 2 • STEP ideal scenario – Vædderen is not in a favorable position

  34. Response – DSC received Time 20:00 20:30 19:53 – Tórshavn Radio receives automatic DSC 20:10 – Sends mayday relay 19:55 – Try to contact the vessel Torshavn Radio MRCC Torshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov) 20:15 – MRCC decides to send Bell 412 and Vædderen 20:10 –Confirmation of name and rough position 19:56 – MRCC gets informed about the DSC 20:00 – MRCC contact Reykjavik 19:58 – “On hold” watch is called 20:05 – Is informed that Bell 412 can fly in this weather 20:13 – MRCC informs FRK about the situation 19:57 – MRCC informs about the situation 20:15 – Vædderen is sent to position by MRCC, starts preparing Lynx 19:57 – Brimil is sent to position by MRCC 20:19 – MRCC informs. Is told to be “stand by”. 19:57 – MRCC informs about the situation, AA gets prepared 20:15 – The AA Bell 412 is given “Go”

  35. Response – DSC received Time 20:30 21:00 20:33 – Sends mayday relay 20:31 – Channel 16 open Torshavn Radio MRCC Torshavn FRK Vædderen Vædderen Helicopter (Lynx OY-HSR 134) Brimil Tjaldrid AA - Bell 412 (and tower) Other vessels (Leinebris, Viktor Mironov) 20:30 – MRCC change of watch 20:30 – AA Bell 412 airborne 21:15 – Is on scene

  36. Agenda • Introduction • STEP-Analysis • Cause analysis • Alternative potential scenario • Improvement areas • Ideal scenario • Discussion

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